Apply for a dog

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Please complete the application enquiry form below as fully and accurately as possible to enable us to best assess your needs. We recommend you read our FAQs and check our eligibility criteria before applying. Once we receive your form one of the team will be in touch to discuss your application in more detail.

Family Details

Email *

Name of parents / guardian *

Date of application *

Home Address *

Telephone Number *

Mobile Number *

How did you hear about Autism Life Dogs ? *

If you answered 'Other' above, please provide further details

Child's Details

Full Name *

Date of Birth *

Height *

Weight *

Please provide details of any diagnosis given *

Date of diagnosis *

Has your child had much experience around dogs and what is their response? Does your child seek comfort and/or interaction with dogs? Please provide as much information as you can here *

Behaviour, Interests & Education

Does your child have an EHC Plan or a statement of special educational needs? *

What type of schooling does your child attend ? *

Pre-School

Mainstream

SEN Unit

Specialist School

Home Education

Family Life

Full names of any other adults living in the family home *

Does the child have any siblings who live at home ? If so, please state names and ages *

Do any other family members have any disabilities or ongoing health issues? *

Does the primary parent/carer work outside of the family home? *

If so, please state the hours of employment for the primary carer on a daily basis. Please note we are unable to place assistance dogs in homes where the dog will be left alone for long periods of time.

What are your hopes/expectations for how an assistance dog can support your child and family? *

Housing Information

Do you live in *

the city

the suburbs

a rural area

other

Do you live in a *

house

flat / apartment

bungalow

Do you have a garden that is accessible from your residence *

Yes

No

Is your garden completely fenced ? *

Yes

No

Have you discussed getting a dog with other members of your household? *

Yes

No

Do you have any pets currently living in your home ? *

Yes

No

If yes, please indicate how many with type / breed / age

Have you ever had a dog before ? *

Yes

No

Do you require a Fundraising Pack? *

Yes

No

Lifestyle

Please, describe the child’s typical daily schedules and activities. This information will give us some insight into what they do, how they spend their time and environments into which they regularly go.

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Sunday *

Please, list hobbies or activities that the child enjoys that may not fall into their typical routine *

Please, tick all types of transport used: *

own car / family car

taxi

public transport

Do you understand that there is a donated financial contribution for the placement of an autism assistance dog and that once legal ownership is transferred you will have financial responsibility of caring for the dog including costs for food, insurance and veterinary costs? *